Ingenix Coding Lab: Coding from the Operative Report, 2005

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ISBN: 9781563376320 | 1563376326
Cover: Paperback
Copyright: 11/1/2004

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This manual provides instruction on gleaning the proper information from physicians' documentation. Beginning with a discussion of operative reports and their importance to the coding process, the book includes examples of operative reports and operative notes, information-needed scenarios, and is organized by the CPT chapter in which each service falls. Book jacket.

History	p. 1
Early Record Keeping	p. 1
Hospital Records	p. 1
Record Keeping in America	p. 2
Standardized Record Keeping	p. 2
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)	p. 2
Summary	p. 4
Discussion Questions	p. 4
Documentation	p. 5
Content	p. 5
Timeliness	p. 6
Operative Reports	p. 6
Summary	p. 8
Discussion Questions	p. 9
Coding	p. 11
Applying Diagnosis Coding	p. 11
Diagnosis Coding Guidelines	p. 13
Applying Procedure Coding Guidelines	p. 16
HCPCS System	p. 17
Anesthesiology	p. 18
Future Coding	p. 18
Summary	p. 20
Discussion Questions	p. 20
Reimbursement	p. 21
Medicare	p. 21
Payment Systems	p. 22
Medicare Claims	p. 24
Summary	p. 24
Discussion Questions	p. 24
Fraud and Abuse	p. 25
Fraud	p. 25
Abuse	p. 25
Sanctions	p. 26
Compliance	p. 26
Summary	p. 28
Discussion Questions	p. 28
Operative Report Coding	p. 29
Names and Terms That Describe Operative Reports	p. 29
Operative Report Coding Guidelines	p. 31
The Operative or Procedure Progress Note	p. 33
Retrieving Information from Documentation in the Operative Report	p. 36
Underdocumented or Incorrect Information	p. 37
Code Selection	p. 37
When to Seek Clarification or Additional Information from the Physician	p. 38
Integumentary System (10021-19499)	p. 39
Introduction	p. 39
Anatomy-The Skin	p. 39
Incision and Drainage of Abscess	p. 41
Incision and Removal of Foreign Body	p. 43
Incision/Aspiration of Hematoma	p. 46
Complex Incision and Drainage	p. 48
Debridement Necrotizing Soft Tissue Infection	p. 50
Debridement with Removal of Foreign Material	p. 51
Debridement	p. 53
Biopsy of Skin	p. 55
Removal of Skin Tags	p. 57
Shaving/Excision of Lesions (11300-11646)	p. 59
Excision of Pilonidal Cyst	p. 62
Insertion/Removal of Contraceptive Capsules	p. 63
Repair (12001-13160)	p. 64
Adjacent Tissue Transfer (14000-14350)	p. 67
Skin Grafts (15000-15776)	p. 69
Blepharoplasty (15820-15823)	p. 71
Burns, Local Treatment (16000-16036)	p. 73
Destruction of Benign or Premalignant Lesions (17000-17286)	p. 74
Breast (19000-19499)	p. 76
Musculoskeletal System (20000-29999)	p. 83
Introduction	p. 83
Anatomy	p. 83
General Information	p. 86
Wound Exploration	p. 89
Biopsy (20200-20521)	p. 91
Foreign Body	p. 94
Arthrotomy, Arthroscopy, and Arthroplasty	p. 96
Hip Arthroplasty	p. 101
Excision of Cysts, Lesions, and Tumors	p. 104
Knee Arthroplasty	p. 106
Excision Bone Cyst/Tumor	p. 107
Fascia of Hand and Wrist	p. 109
Fractures and Dislocations	p. 111
Repair, Revision and/or Reconstruction	p. 115
Ganglia of Wrist	p. 117
Muscles and Tendons	p. 119
Spine	p. 121
Respiratory and Cardiovascular Systems (30000-39599)	p. 125
Introduction	p. 125
Respiratory System	p. 125
Turbinates	p. 126
Nasal/Sinus Endoscopy	p. 127
Trachea and Bronchi	p. 129
Bronchoscopy	p. 130
Larynx	p. 131
Lungs and Pleura	p. 135
Thoracotomy	p. 137
Cardiovascular System	p. 139
Coronary Arteries and Veins	p. 143
Central Venous Access Procedures	p. 148
Hemic and Lymphatic Systems	p. 150
Bone Marrow Biopsy	p. 152
Digestive System (40490-49999)	p. 153
Introduction	p. 153
Endoscopy	p. 153
Salivary Glands and Ducts	p. 155
Pharynx, Adenoids, and Tonsils	p. 158
Esophagus	p. 160
Intestines	p. 167
Appendix	p. 170
Rectum	p. 171
Biliary Tract	p. 173
Laparoscopy-Abdomen	p. 175
Hernia Repairs	p. 176
Urinary, Male Genital and Female Genital Systems, and Maternity Care and Delivery (50010-59899)	p. 179
Introduction	p. 179
Urinary System	p. 179
Lithotripsy	p. 182
Urinary System Testing	p. 184
Urinary System/Urethropexy	p. 185
Cystourethroscopy/Bladder	p. 186
Male Genital System	p. 188
Female Genital System/Bladder Suspension	p. 190
Hysterectomy	p. 192
Maternity Care and Delivery	p. 194
Cesarean Delivery	p. 196
Cervical Cerclage	p. 198
Endocrine and Nervous Systems, Eye and Ocular Adnexa, and Auditory System (60000-69990)	p. 199
Introduction	p. 199
Endocrine System	p. 199
Nervous System	p. 202
Craniotomy and Electrophysiologic Monitoring	p. 203
Sterotactic Radiosurgery	p. 206
Diskography/Diskectomy	p. 208
Suture of Digital Nerve	p. 211
Eye and Ocular Adnexa	p. 212
Vitrectomy	p. 214
Tympanostomy	p. 216
Auditory System	p. 217
Radiology (70010-79999)	p. 219
Introduction	p. 219
Diagnostic Radiology (Diagnostic Imaging)	p. 223
Head and Neck Codes	p. 225
Spine and Pelvis Codes	p. 226
Urinary Radiology	p. 227
Aorta and Arteries	p. 228
Nuclear Medicine	p. 231
Medicine (90281-99569)	p. 233
Introduction	p. 233
Otorhinolaryngology	p. 233
Cardiovascular Therapeutic Services	p. 237
Cardiac Catheterization	p. 239
Heart Catheterization	p. 242
Pulmonary	p. 244
Allergy and Clinical Immunology	p. 245
Neurology and Neuromuscular	p. 246
Nerve Conduction Studies	p. 247
Physical Medicine and Rehabilitation	p. 249
Abbreviations	p. 251
Glossary	p. 259
Index	p. 275
Table of Contents provided by Rittenhouse. All Rights Reserved.

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Ingenix Coding Lab: Coding from the Operative Report, 2005

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